sacculations, in the esophagus of a boy aged four
years. The strictures were divulsed seriatim from above downward with
the divulsor, the esophageal wall, D, being moved sidewise to the
position of the dotted line by means of a small esophagoscope inserted
through the upper stricture, A, after divulsion of the latter.]

_Location of Cicatricial Esophageal Strictures_.--The strictures are
often multiple and their lumina are rarely either central or
concentric (Fig. 97). In order of frequency the sites of cicatricial
stenosis are: 1. At the crossing of the left bronchus; 2. In the
region of the cricopharyngeus; 3. At the hiatal level. Stricture at
the cardia has rarely been encountered in the Bronchoscopic Clinic.
Stenosis of the pylorus has been noted, but is rare.

_Prognosis_.--Spontaneous recovery from cicatricial stenosis probably
never occurs, and the mortality of untreated small lumen strictures is
very high. Blind methods of dilatation are almost certain to result in
death from perforation of the esophageal wall, because some pressure
is necessary to dilate a stricture, and the point of the bougie, not
being under guidance of the eye, is certain at sometime or other to be
engaged in a pocket instead of in the stricture. Pressure then results
in perforation of the bottom of the pocket (Fig. 98). This accident is
contributed to by dilatation with the wrinkled, scarred floor which
usually develops above the stricture. Rapid divulsion and internal
esophagotomy are mechanically very easily and accurately done through
the esophagoscope, and would yield a few prompt cures; but the
mortality would be very high. Under certain circumstances, to be
explained below, gentle divulsion of the proximal one of a series of
strictures has to be done. With proper precautions and a gentle hand,
the risk is slight. Under esophagoscopic bouginage the prognosis is
favorable as to ultimate cure, the duration of the treatment varying
with the number of strictures, the tightness, and the extent of the
fibrous tissue-changes in the esophageal wall. Mortality from the
endoscopic procedure is almost nil, and if gastrostomy is done early
in the tightly stenosed cases, ultimate cure may be confidently
expected with careful though prolonged treatment.

[FIG. 98.--Schema illustrating the mechanism of perforation by blind
bouginage. On encountering resilient resistance the operator, having a
false conception, pushes on the bougie. Perforation res